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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH GGPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Nem gKW7 cf3� 1 <br /> OWNER I OPERATOR ,I n <br /> CHECK If BILLING ADDRESS Gr <br /> FACILITY NAME <br /> SITE ADDRESS 5 <br /> / S (� <br /> t et Number Direction Street Name cityZi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SStreet Number ZC� ,/Street Name <br /> CITY_ 1 � � / STATE ZIP '?-45 <br /> C 7/(O 2, <br /> u PHONE#t EXT' L APN# LAND USE APPLICATION# /J <br /> (gat?)q)1v-7 bsc,ol 17 CX>G <br /> PHONE#2 EXT. BOS DISTRICT LOCATION(TE <br /> ( ) 1 e©C— <br /> rxs <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> 0v h rl l�1 1 CHECK If BILLIN'G ADDRESS <br /> BUSINESS NAMEI ry ExT. <br /> 615 G1 P NE# ��0 —Sr vty3 <br /> HOME or MAILING ADDRESS �^ /I- w / /d,� :%/A // FAX# <br /> / I ( fi f'A'! (�/� ) <br /> CITY 5- , STATE 0•— ZIP <br /> dI/L(/1 un ✓��l .J� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , T TE d AL S. <br /> 11 r`,Y_ / <br /> APPLICANT'S SIGNATURE: � DATE: `� - 1" J <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER Mr OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY,proof of authorization to Sign i5 required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided to me or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: <br /> F k <br /> COMMENTS: RW4\ XAwLA,0- -16*1 <br /> to <br /> 5b) l�I c4 ti t-,Q NM co��18 <br /> Fay(R•'�Tq�N2Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: .�X <br /> ASSIGNED TO: t EMPLOYEE#: DATE: V J <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: ,/ <br /> Fee Amount: 15 Amount Pai lS� l]V- Payment Date <br /> Payment Type G! Invoice# Check# ReceiveriBy: <br /> EHD 48-02-025 SR FORM(Golden Red) <br /> 07/17/08 <br />